Statistics from the UK reveal that prescriptions for painkillers and antidepressants continue to rise despite concerns over dependence and debilitating withdrawal effects. The British Medical Association (BMA) Board of Science has released a report that acknowledges changes to medical practice, research and policy necessary for addressing the dependence and withdrawal effects of benzodiazepines, opioids, and antidepressants.
The Board of Science conducted a review of the issue— Prescribed drugs associated with dependence and withdrawal – building a consensus—by soliciting evidence on dependence and withdrawal from governmental, support and charitable organizations.
The researchers collected all of the responses submitted from the various agencies and analyzed it for common themes and overarching patterns. The analysis revealed seven themes, which touched on the following issues:
Managing benzodiazepine dependence and withdrawal in general practice
It was reported that many general practitioners use a rapid tapering or “cold turkey” strategy to manage prescription benzodiazepine dependence and that these practices often force patients into support groups and withdrawal charities. Rapid tapering, according to the support groups, is often associated with the worst cases of withdrawal and it appears that general practitioners often underestimate the effects of the dependency and “impose unrealistic time scales on the pareing process.” Seventy-one percent of respondents reported feeling unsupported by their doctor after the dependency was acknowledged. In response, the report suggests that new guidelines should emphasize that “the rate of withdrawal tapering should be gradual and flexible around the patient.’
A subtheme identified for this issue draws attention to the long-term prescribing of benzodiazepines against clinical guidelines. Current guidelines suggest that benzodiazepines be used for only 2-4 weeks, including the tapering period, but many of the organizations reported that these parameters are rarely followed. The lack of funding and attention given to non-pharmacologic treatments and therapies was cited as one reason that many patients may end up taking the drugs over the long-term.
Governance and service provision for patients suffering with prescription drug dependence and withdrawal
Nearly all responses indicated a gap in care for those who have become addicted to prescription drugs, according to the report. The support organizations claim that existing drug rehabilitation and withdrawal services that are designed for illegal drug use are not adequately trained or resourced to provide the services necessary for this patient group. The responses also criticized reliance on volunteer and private organizations to fill this gap and care.
Harms associated with prescription benzodiazepine dependence and withdrawal
Withdrawal charities, support groups and individuals affected by benzodiazepines reported a number of potential harms from the benzodiazepine use, including: “physical (seizures, headaches, palpitations), psychiatric (hallucinations, psychotic episodes, anxiety, panic attacks, suicidal intention), psychological (trauma) and social harms (loss of job, leave education, financial instability).”
In addition, research submitted by Catherine Pittman revealed that the length of recovery from dependence may be longer than previously recognized. Her study found “96 percent of long-term prescribed users continued to experience withdrawal symptoms for an average of 14 months after withdrawal and cessation from benzodiazepines.” There was also an indication that there may be enduring symptoms such as tinnitus, anxiety, motor symptoms, gastrointestinal issues, and paresthesia (a pricking sensation caused by nerve damage).
Attitudes towards the cause of prescription drug dependence and withdrawal
The report acknowledges a noticeable difference of opinion about that causes of prescription drug dependence between the governmental and practitioner organizations on one side and the support groups, withdrawal charities, and affected individuals on the other. The first group attributed patterns of dependence to individual differences in patients while the latter placed accountability on the inappropriate prescribing practices of the doctors. Research submitted by Pittman appears to substantiate the claims of the second group. The report states:
“Her research found no difference in the emergence and experience of withdrawal symptoms between those individuals prescribed benzodiazepines for psychiatric versus non-psychiatric (e.g., seizures, muscle tension, recovery from surgery) conditions. This suggests that long-term exposure to benzodiazepines per se may account for the severity of withdrawal experienced by prescribed users, and subsequently difficulties terminating use, rather than pre-existing individual differences in mental health status.”
The support groups, charities, and individual also indicate increased stigma from medical professionals after a patient becomes dependent on the drugs prescribed to them.
Research and data on prescription drug dependency and withdrawal
Many respondents pointed to the lack of research being done on prescription drug dependence with benzodiazepines, analgesics, antidepressants and Z-drugs. In addition to research on the drug effects, more work needs to be done to develop best practices and clinical guidelines for first identifying dependence and then deciding on the most advantageous course of action.
Opioids prescribed for chronic non-cancer pain
There are concerns about the increased use of opioids for chronic pain. The withdrawal symptoms from dependence on these drugs were recognized to be severe and potentially disabling. “Despite widespread prescribing, the safety and efficacy of long-term prescribed opioids for chronic non-cancer pain was reported to be unknown.” Similar to benzodiazepine prescriptions, responses again noted that while there are existing guidelines for opioid prescribing that they are not always followed and that more work needs to be done to understand why these practices are occurring.
There was a widespread concern that antidepressants are being prescribed without a clinical need and that they may be unsafe and also cause dependence and withdrawal symptoms after long-term use. Respondents pointed to the research evidence that suggests that the drugs may be ineffective for mild and moderate depression and that their benefits are unclear even in cases of severe depression. Charity and support groups reported that antidepressants may cause severe mood disturbances, suicidality, and, potentially, dependence, but practitioners reported the long-term benefits and relative safety of antidepressants. For those that acknowledged the potential withdrawal effects of coming off of antidepressants, there was also agreement that there is no well researched or recognized approach for managing antidepressant withdrawal.